My new book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Wednesday, December 13, 2017

In a New York Times “Upshot”
piece on December 7, 2017, Dhruv Khullar notes that “Being
a doctor is hard. It’s harder for women”. I do not doubt it, especially the
second part. Dr. Khullar goes through a host of reasons for why it is harder
for women, most of them related to sexism (including internalized sexism) such
as having children, having the bulk of the responsibility for maintaining a
household, being seen as less smart or competent by supervisors and colleagues,
and on and on. The idea that “being a doctor is hard” is also one I can agree
with. However, Dr. Khullar’s piece focuses mainly on residents, medical school
graduates who are in specialty training. He opens it with a parody of Tolstoy’s Anna Karenina: “Happy
medical residents are all alike. Every unhappy resident would take a long time
to count.”

This is where I take issue, at least a little, with his
perspective. Mainly this is because I do not remember being unhappy as a
resident several decades ago. Tired, often, but not unhappy. I liked the work I
did, as a family medicine resident at Cook County Hospital in the late 1970s,
both caring for patients in the hospital on a variety of specialty services and
in our hospital and community-based outpatient practices. I liked my
colleagues, in family medicine and in other departments, and liked working with
them. I learned a lot from them. I don’t recall most of my colleagues being
unhappy either, and checked with a few with whom I am still in touch, and they also
do not recall being unhappy. One, indeed, said he wasn’t even that tired, as he
slept through most noon conferences!

There were not only fewer women residents and medical
students, but they were (in my
experience) less likely to be married and have children. A small
minority of students in my medical school class were married, but now it is
common. I married (another resident) and we had our first child during
residency, but when I was a program director, the majority of my residents were
married by the time they started (I remember a year when five women started the
program with different last names than they had interviewed with).

Yet several studies do tend to support Dr. Khullar’s
assertions about residents in general being unhappy, as well as feeling
overworked, and I think my experience as a family medicine program director and
that of one of my colleagues (and former wife) as an internal medicine program
director, support the idea that more recent residents seem unhappier, at least
compared to us, then, at that hospital. There could be many reasons for this,
including the possibility that memory is inaccurate, and distance dulls the
pain, but I don’t think that this is the main one.

Another reason could, theoretically, be that the work was
less or easier back then. Indeed, at Cook County Hospital in the late 1970s
most residents had every-fourth-night call, a direct result of having a
residents’ union in the hospital that negotiated working conditions. Dr.
Khullar asserts that “The structure of medical training has changed little
since the 1960s, when almost all residents were men with few household duties.”
I think that he is wrong about this. Residents who trained in the late ‘60s and
early ‘70s, before me and the union, often had every other night call (yes,
work all day and all night and the next day, then go home and crash and come
back to work). There is a reason that these doctors in training are called “residents”
and “interns”; Cook County had a residents’ residence, where many actually
lived and all had “call rooms” where we could get, maybe, a couple of hours
rest. Although call was every 4th night, there were no other “hours
rules”; Cook County had 16 medical services, with 4 taking call every 4th
night and taking every 4th admission, and the two interns on each
service thus taking every 8th, but this could easily be 10 or more
patients per intern per night. And one didn’t get to go home the next day at a
certain time even though other services were on call. One specific example was
CT scans; Cook County Hospital didn’t have one then, but the private hospital
across the street, Rush, did. We could take our patients there, but only at
night, when they were finished with their routine scans, and the patients had
to be accompanied by the Cook County intern caring for them. Often at midnight,
the night after they had been admitted. Residents also did most of the work;
attending physicians were not in the hospital at night, and in the day had time
only to round on new admissions and those who were very sick. Even having every
4th night call was a big change from every other or 3rd
night, but I do not think we had less work than most residents have today.

My point is not to try to disparage the tiredness or
unhappiness of more recent residents by citing the “bad old days” when things
were worse and we had to walk to school in the snow uphill both ways (although
the weather was worse in Chicago then, thanks to global warming, and it was
possible in winter to arrive and leave in the dark, and thanks to the system of
tunnels under Cook County never see the sun). It is simply to note that workload
is not the sole, or main, determinant of whether residents are happy or not.
And here I can just speak from my limited experience. Many of us who were
residents at Cook County Hospital were there for a reason. From the several
Chicago medical schools and those further afield, we came because we were
committed to providing the best possible care for people who were poor,
underserved, and often ignored. We knew, and daily had reinforced, that our
best efforts could not make up for the impact of poverty and discrimination;
that despite the fact that the hospital did not charge patients, even for
outpatient medications (although they had to wait hours for their prescriptions
to be filled) the obstacles to their health were enormous. But we, most of us,
cared, and tried to do our best. Our residency was not just a step on the path
to a career as a successful physician, but an opportunity to work with and try
to help people who had real need. We had a mission, not necessarily in the
religious sense (although many who came as residents to Cook County were
inspired and motivated by their religious convictions).

And, as a result of this shared mission we were each others’
greatest support, personally as well as medically. Medically, the 4 services
with 4 residents, 8 interns, a chief resident, and medical students, shared an “admitting
ward”, as so we were all together, to consult, to review x-rays, and help with
procedures. But personally, we could reinforce each others’ beliefs, and
provide support, succor, and even inspiration. I think that was the biggest
part, for me at least.

Certainly, my experience at Cook County may not have been
typical for residents of the era (indeed, that is part of why I chose it).
Certainly, there were unhappy residents then, and uncommitted residents then,
and women residents who were burdened with the care of the household and
children. And, as certainly, there are now and have been ever since, happy and
committed and inspirational residents. I guess “if you’ve seen one, you’ve seen
one”. But I am pretty sure that a commitment to something greater than yourself
and your self-interest helps a lot, as does training in a place where many of
your colleagues feel the same way. And maybe that’s a lot of what we need as
doctors, not just residents.

Wednesday, November 15, 2017

“Let’s do it to them
before they do it to us,” was the line with which Sgt. Stan Jablonski
(played by Robert Proskey) dispatched his troops on the old TV show Hill Street Blues. When Sgt. Jablonski
replaced Sgt. Phil Esterhaus (on the death of actor Michael Conrad) they had to
come up with a replacement for Esterhaus’ “Let’s
be careful out there”. Perhaps the show’s writers felt it was ok coming
from the shorter, pudgier actor than the 6’6” Conrad, but it has a very
different meaning and very different connotation, an “us against them”.

Presumably the “them” was bad guys, not the regular folks
that the police were supposed to be there to “protect and serve” but now, 30
years after the show went off the air, we realize how much this was, sadly,
prescient. I am not going to recite the names of all the black men – and
children – killed by police in recent years, including Tamir Rice, Michael
Brown, Freddie Gray, Philando Castile, but
it is an epidemic. Yes, more white people have been killed by police than
black in both 2016
and
2017 – about twice as many – but the proportions are way off given that
just over 12% of the population of the US is black. And what has been even more
graphic is the lack of convictions, and frequently even prosecutions, of the
perpetrators.

If these deaths were not at the hands of police, but rather
had a different cause – an odd virus that struck down black men when being
confronted by the police, or a very selective alien attack, we would not
hesitate to call it an epidemic and search for the cause. But this issue is
political, it is personal, it is an “us” against “them”, raising the issue is
seen by many to be attack on the police, who heroically and at great risk to
themselves protect us from evil. Certainly, the Governing Council (GC) of the American Public Health Association (APHA), by
far the largest public health association in the nation, did not choose to
identify the killing of black men by police as a public health epidemic when it
voted, 65%-35%, against a resolution so designating it at the recent meeting in
Atlanta. The resolution had been introduced a year before, and sent by the GC
back to the authors to make changes to the language, which was done. But it was
not sufficient.

If it was the language, felt, for example, to be denigrating
to police, that was the issue, members of the group could have introduced and
passed amendments to correct it. This point was made (after the vote) by APHA
immediate past President Camara Jones, MD MPH PhD. But it was not the issue;
the GC (and thus, the APHA) did not want to take a stand identifying the
killing of black men by police in the United States as a public health
epidemic. Speakers against the resolution cited personal but irrelevant
concerns like “my brother is a policeman, and he is a good man”, as well as
saying “the data is not sufficient to make the case that it is an epidemic”,
which is patently false. The vote was portrayed as a scientific decision, but
it was clearly a political one, a decision by the overwhelmingly white group to
put their fingers in their ears, their hands over their eyes, and shut their
mouths rather than standing up and saying “this is a problem”.

Many of these killings have been of people (usually men, but
sometimes women or children) who were not involved in committing crimes. They
result from the heightened suspicion police hold of black people in general. If
you don’t believe that, you’re probably white. Just before the vote, I was at
an session at the meeting discussing police violence against black men. Most of
the group was minority (predominantly black) and were relatively young public
health professionals, students, and junior faculty in schools of public health.
A couple of speakers introduced the issue, but then opened the floor. One by
one, in random order, unrehearsed, person after person in the group talked
about their fears and their experiences; these were not prepared in advance,
but slowly came out, one giving rise to another. A government employee noted
that she had two young sons, and worried about their safety. Another woman, a
public health professional, noted that her flight to Atlanta departed at
5:30am, so she’d left her home in a mostly-white suburb at 3:30am to go to the
airport. She was followed by a police car all the way into the city. Another
woman, a professor, talked about driving to a neighboring state and being
followed by a police car that eventually stopped her for no reason or
violation; in the process the officer asked “if you’re a teacher, why aren’t
you in school?” The stories went on and on, from the mouths of professional
people, most of them, in fact, women.

Although many people would disagree, often virulently in
with this age of Trump giving loud voice to aggrieved white men, being white in
America is a privilege. It is a privilege of not thinking that you will be
followed by police, or pulled over by them, or subjected to inappropriately
probing questions by them. It creates an illusion, obviously held by the
majority of the GC of the APHA, that it is mostly criminals, or
“probably-criminals”, or people who look like they might be criminals, who are
followed by, stopped by, and sometimes killed by police. But that is not the
experience of black people in this country, not the black men shot by a police
officer who makes up a story about being threated, nor of the middle-class
professionals who told their stories at that APHA session. It is not the
experience of the young woman who drove me to the Atlanta airport from the
conference; in talking she said she had a 3-year old son and I asked if she
feared for his safety not just from gangs but from police. In response she said
she did, and pointed to a button hanging from her rear-view mirror and said “my
uncle was killed by the police 3 years ago”. I don’t know what occurred with
her uncle beyond what she told me, but I suspect it is not fate, coincidence,
or Kismet that caused my driver to have her own story to tell, but rather the
ubiquity of this experience among black people in America.

What about the police? Don’t we have to worry about the
safety of the people who risk their lives each day to protect us? What about
the fact that there are many (if not enough) minority police officers? To
identify the current situation, not only the killings but the very real sense
of most black people in this country that they do not have the same rights as
whites, that they are, by definition, “suspicious” because of their color, does
not require denigration of all police officers. Indeed, the families
(especially male family members) of black police officers, and even the
officers themselves when off-duty, experience the same indignities (and worse) as
other black people.

It does mean that the idea that a police officer’s first
loyalty is to other officers rather than to the community that they “protect
and serve” must be very narrowly construed. Rather than a “thin blue line” of
brothers (always, it seems, brothers, not sisters), it means that we should
have tighter standards for police, excluding those who are overtly and
viciously violent and racist. It means better training in identifying a
situation in which you see through your prejudice and not through reality, and
how to de-escalate. It means that when an officer kills a person innocent of a
crime, it is not enough for other officers to have not “done it”; they must, if
they were unable to prevent it, disclose it and discourage it and, yes, testify
against the perpetrator. Police officers who do so are not “traitors”, they are
heroes who allow the force to be thought of as we want to think of them.

The fact that even the most respectable and middle-class
black people have to fear interactions with police (even when they are the ones
who have called them!) is a societal scandal. The enormously disproportionate
killing of black men by police is an epidemic, and like all epidemics we must
identify it as such, find the cause, and treat it.

Wednesday, November 1, 2017

It is 2017. It is more than 100 years since Margaret Sanger
advocated for contraception, and more than 50 years since the oral contraceptive
pill became available. The last two generations of women – and men – have never
known a world where there was no effective form of contraception. They probably
do not recall when even condoms, although “over the counter” (in that no
prescription was required) were stocked “behind the counter” and required
requesting them from the pharmacist often with (if you were young) a
disapproving glare, and maybe worse, a raft of questions.

The verbal and physical indignations and worse, including
even murder committed on unmarried women who got pregnant and were unable, of
course, to have access to abortion should be things of the past. They are,
horrifically documented in Dan Barry’s New
York Times piece “The
Lost Children of Tuam”. The film “The Magdalene
Sisters” shows the intolerable treatment of girls who may not have even
gotten pregnant but were, perhaps, just a little too familiar with boys. Both the
Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was
perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic
Church, but the treatment of women in England and the US were also inexcusably harsh.
The British drama “Call
the Midwife” tells the story of an unmarried teacher who gets pregnant in
the early 1960s and is fired from her job (morally unfit to care for
children!), tries to self-induce abortion with a coat hanger, and almost dies.
Finally, post-hysterectomy so that she will never be able to have children, she
is driven out of town. The most sympathetic characters in the show see it as
sad, but none indicate it is horrific, immoral, and inhuman. And this was
commonplace, even in the 1960s and beyond.

We should not, in 2017, even be discussing the availability
of contraception, not to mention whether it works. Amazingly, we are. Teresa Manning, appointed by President Trump in May
to be the director of the Office of Population Affairs, the main family
planning arm of the federal government, is not only
a former employee of two anti-abortion groups, but has expressed
skepticism of the effectiveness of contraception itself! Manning, a lawyer
and not a health professional (although this is not an excuse), is completely
wrong. The data is in. Contraception dramatically decreases unplanned pregnancy
(regardless of marital status). Time recently
ran an article accurately describing the science titled “No,
birth control doesn’t make you have riskier sex”. That is the truth, but in
fact, even if it is was associated with riskier sex for some people, that would
be no reason to restrict access to it. The more contraception is available, the
lower the rate of bad outcomes of virtually all kinds. It even, of course,
reduces the rate of abortion; in fact, the only two things ever to have been
shown to significantly reduce the rate of abortion are comprehensive and
accurate sex education and easy and cheap availability of contraception.
Indeed, the degree to which contraception is effective in decreasing the
incidence of unplanned and undesired pregnancy is directly related to the ease
of its availability, including financial availability. Unsurprisingly, reducing
the cost of and increasing the ease of access to contraception has the greatest
impact on teens and on the poor.

So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t
think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary”
come to mind as better adjectives) has reversed
the ACA’s requirements that employers and insurers provide contraception at no
cost to women. Politically, it is part of the administration’s efforts to
dismantle the ACA piece by piece, since they were unsuccessful in doing it as a
whole. Morally, it is an imposition of a minority’s religious values on the
rest of us, and is particularly ironic being spearheaded by Donald Trump. It
will cause great harm to individual women (and men) and to the society as a
whole. Arguments that the cost of contraception is “only” $50 a month may wash
with those in the middle class and up, but for poor women and teens, $50 a
month is a lot. The most effective methods of contraception, IUDs and implants
(collectively referred to as LARC, long-acting reversible contraception) may
have a lower amortized cost over the use period but a high upfront cost that is
unaffordable, without subsidies, for many women. (The reason, lack of cash on
hand, is the same one that leads many poor families, as described by Barbara
Ehrenreich in her wonderful and depressing book “Nickel and Dimed”, to live in expensive weekly motel rentals –
the overall cost may be more than an apartment, but the upfront cost, including
deposits, rent in advance, etc., is prohibitive for them.) The impact on the
teens who will be denied free access is described
movingly by a pediatrician in Vox.

The other important impact of such a policy would – and perhaps
will -- be on the economy. This is articulately addressed in a
column by Bryce Covert in the NY Times,October 29, 2017. The reasons start
with individual women, and the cost of purchasing birth control, money which
will not be available for them to spend on other goods – with more than 57
million women using contraception, in one year that is $1.3 billion. But the
larger impact is societal – women who cannot control their own reproduction,
who do not know when and if they will get pregnant – are in a poorer position
to contribute to the workforce and to the economy. Again, going back to the
history I address at the start of this piece, we know this empirically, not
just theoretically:

…
a raft of evidence has definitively found that when women gained greater access
to the pill in the late 1960s and early ’70s, they were able to delay marriage
and childbirth and invest in careers through education, job training and
staying in paid work….Legal access to the pill transformed the economy in that
era. It increased young women’s labor force participation by 7 percent….about a
third of the increase in how many women attained careers in fields like law and
business was due to birth control. Women with earlier access to the pill also
made 8 percent more than their peers, and the pill was responsible for about a
third of the decrease in the gender wage gap by 1990.

And it is still critical. Perhaps Trump himself is just
cynically pandering to his base, and probably much of that base depends upon
contraception, women directly but men just as much. Opposition to contraception
cannot be justified except by the small minority of religious purists (and of
course they are welcome to not use it); opposition to making contraception
easily and freely available is almost as bad, as it is completely
discriminatory. It is still, as Covert describes,

…still
playing the economic role that it did in the 1970s. About half of women who use
it say they do so to complete education or to get and keep a job. Contraception
is still increasing the share of women who get educated and get paid work,
particularly prestigious jobs.

Easy and affordable (affordable for all those who need to
use it, not just billionaires or even the upper middle class!) is not a “women’s
issue”, it is not a “special interest” issue. It is a core need for people. People
with the views of Teresa Manning should not be given center stage, and
certainly not given authority over contraception. We need to guarantee
permanent access to contraception for all, and for accurate sex education.

Sunday, October 22, 2017

"A well
regulated Militia, being necessary to the security of a free State, the right
of the people to keep and bear Arms, shall not be infringed."

Recognize those words? The Second Amendment to
the Constitution of the United States, what all the fuss is about. In addition
to the confusing use of commas, apparently more generously applied in the 18th
century, we have two key phrases. The final phrase, “shall not be infringed”,
is read by the NRA and other “gun rights” zealots (and it is important to
remember that only a minority of NRA members, and a smaller minority of gun
owners, support this position) to mean essentially “no legislation regulating
guns in any way”. That includes assault rifles, semi-automatic and maybe even
automatic rifles, armor-piercing (“cop killer”) bullets, and any other weapon
or gun modification that creative minds can come up with. Of course, it has
been noted that none of these types of weapons were available at the time of
the Constitution, when firearms were muzzle-loaded muskets, quite different
from current weapons (see graphic).

The NRA take the position that there is
qualitatively no difference, as noted by its President, Wayne LaPierre, after
the December 2012 massacre at Sandy Hook Elementary School: "Absolutes do
exist. We are as ‘absolutist’ as the Founding Fathers and framers of the
Constitution. And we’re proud of it!" Others (including me, in case you
were wondering) would disagree, and say that clearly at some point the
quantitative difference becomes qualitative. This is the only amendment they
are absolutist about; the First Amendment says “Congress shall make no law…
abridging the freedom of speech…”, but it has long been settled that it is not
OK to yell “Fire!” in a crowded theater.

The other obviously important phrase is “A well regulated
Militia”. Again, obviously, this has been the source of much discussion, with
the NRA taking the position that “Militia” just means “everyone” (kind of a
stretch), and (as far as I can tell) “well regulated” means, um, not regulated
at all. Is this cherry picking the words one wants? Maybe, but I can’t imagine
how it is possible to ignore completely the words “well regulated”. But does it
matter? Yes, when we live in a country where

The
36,252 deaths from firearms in the United States in 2015 exceeded the number
of deaths from motor vehicle traffic crashes that year (36,161). That same
year, the US Centers for Disease Control and Prevention reported that 5 people
died from terrorism. Since 1968, more individuals in the United States have
died from gun violence than in battle during all the wars the country has
fought since its inception.

Those are staggering numbers, and
certainly justify the assertion that it is a “public health crisis”.

The authors also note that “60.7% of the gun deaths in 2015 in the United States
were suicides,” a fact often ignored. That is a majority. A
large majority. If it were an election, 60.7% would be considered a landslide.
But with guns it is a mudslide of death. I have written before about suicide (e.g,
Suicide:
What can we say? December 13, 2013, Suicide
in doctors and others: remembering and preventing it if we can September 14, 2014,Prevention
and the “Trap of Meaning” July 29, 2009) and its
impact on myself and my family, with my son’s successful suicide-by-gun at the
age of 24. My son, to my knowledge, had never used a gun before his final act.
He lived in a state and city with strict gun control laws (some of which,
sadly, have been eliminated by the courts). He was nonetheless able to go to
another state, buy a carbine (terrific choice! No permit needed, even in those
days, like a handgun would require, but short enough to reach the trigger with
the barrel in his mouth!), and use it. It would be easier now, in that state
and many others.

My son was apparently very committed to
this act, and was successful despite some obstacles. But for many, many people
it is the availability of guns that make a spur-of-the-moment decision lethal.
I have noted before that nearly 95% of suicide attempts by gun are lethal while
less than 5% by drug overdose are. My clinical experience is that many suicide
survivors do not repeat their attempts (though many do). The successful suicide
rate for young adult males in low gun control states is several times higher
than in high gun control states. And on and on.

But the epidemic of suicide and murder
and mass murders resulting from the easy availability of guns has not changed
the legal landscape. After the Las Vegas massacre, there was a small ray of
hope that maybe one of the most egregious products the white terrorist Stephen Paddock
used, the “bump stocks” that effectively convert semi-automatic to automatic
rifles, might be limited; even the NRA voiced some possible support. But never
underestimate the cowardice and lack of moral fiber of the Congress; Speaker
of the House Paul Ryan has suggested that this be done by regulation rather
than legislation. This is absolutely because
it will not require any congressperson to actually vote for it and thus be
targeted by the zealots in the next election. Hopefully, not literally targeted
by guns, but do not forget Gabby Giffords and Steve Scalise!

Dr. Bauchner, who is the editor-in-chief
of JAMA, also joined the editors of
several of the other most prestigious US medical journals, New England Journal of Medicine, Annals of Internal Medicine, and PLOS Medicine in an editorial that
appeared in all their journals (this link is the the NEJM), ‘Firearm-Related
Injury and Death — A U.S. Health Care Crisis in Need of Health Care
Professionals’.[2] Again, this emphasizes the fact that guns are a public health
epidemic in the US, and that there is little likelihood of anything being done
at the federal level to stem its carnage. It recognizes that there is a
variable response at the state level, with some states going as far as trying
to legally prohibit physicians from asking about guns in the home (Florida;
since struck
down by the courts) while others have had
stronger regulations. Many legislatures have also acted to prevent the cities
in their states from acting independently to regulate guns in any way. One of
the most insane was the state of Arizona suing to prevent the city of Tucson
from destroying guns seized from criminals. The legislature mandated that they
be sold – thus keeping them on the
streets – and the
Arizona Supreme Court upheld this, saying state
law trumped local ordinances!

Given this situation, the joint editorial
suggests that there are many things that physicians can and should do, including
(quoted):

·Educate yourself. Read the
background materials and proposals for sensible firearm legislation from health
care professional organizations. Make a phone call and write a letter to your
local, state, and federal legislators to tell them how you feel about gun
control. Now. Don’t wait. And do it again at regular intervals. Attend public
meetings with these officials and speak up loudly as a health care
professional. Demand answers, commitments, and follow-up. Go to rallies. Join,
volunteer for, or donate to organizations fighting for sensible firearm
legislation. Ask candidates for public office where they stand and vote for
those with stances that mitigate firearm-related injury.

·Meet with the leaders at your own institutions to discuss how to leverage your organization’s influence with
local, state, and federal governments. Don’t let concerns for perceived
political consequences get in the way of advocating for the well-being of your
patients and the public. Let your community know where your institution stands
and what you are doing. Tell the press.

·Educate yourself about gun safety. Ask your patients if there are guns at home. How are they
stored? Are there children or others at risk for harming themselves or others?
Direct them to resources to decrease the risk for firearm injury, just as you
already do for other health risks. Ask if your patients believe having guns at
home makes them safer, despite evidence that they increase the risk for
homicide, suicide, and accidents. [this
is what the Florida law would have made illegal]

·Don’t be silent.

The first (JAMA) editorial says:

Guns
kill people….the key to reducing firearm deaths in the United States is to
understand and reduce exposure to the cause, just like in any epidemic, and in
this case that is guns.

The fact is that while physicians have
influence and moral authority, so do other health professionals, and, in fact, so
do all of us. So the advice must pertain to all of us.

Key to this fake news is the use
of “fake facts” to support reactionary political agendas. While these agendas
are mostly about making more money for the richest people and corporations
rather than the middle and working-class Americans who support them, they also
exploit a bizarre antipathy toward science among a good hunk of our population.
(One explanation is that science sometimes reveals
facts that are incompatible with pre-existing beliefs, so we reject them.
However, the Catholic Church finally got over its opposition to Galileo, so
maybe there is, eventually, hope.) Indeed, these people don't oppose all scientific
facts, but rather those that make them uncomfortable despite being true. This is suggested by the efforts to
manufacture false “scientific” facts to buttress social agendas. A prominent example
is the use of “fetal pain syndrome” to justify efforts to limit access to
abortion, particularly in the second trimester. The flaw here, of course, is that
the evidence for fetal pain is slim to none, certainly before the third
trimester, as shown is several reviews of the literature, and discussed at
length in this articlein Popular
Science. LiveScience.com notes that “The American College of Obstetricians and
Gynecologists (ACOG) said it considers the case to be closed as to whether a
fetus can feel pain at that stage [20 weeks]
in development.”Of course, while the
number of people who would change their positions on the availability of
second-trimester abortion if they believed that the fetus experienced pain
during the procedure would be small to minimal, it provides a convenient, if
false, cover for efforts to restrict access, including a House bill that passed just this month in Congress.

This use of fake facts and junk
science has recently been expanded beyond restricting abortion to efforts to
limit access to contraception for women. Let’s get this completely
straight: access to contraception has been a terrific thing. It has
given women – and men – much greater control of their reproduction,
dramatically reduced the incidence of unintentional pregnancy (although this
still remains far too high), and, duh!, even reduced the incidence of
abortion. While the decision to use contraception should and does remain
up to the individuals involved, it needs to be easily available to them. Thus access
is critical.For many – including but not limited to teens – access is,
instead, very limited, and there are ongoing efforts in Congress and in many
states to further restrict it. Particularly onerous and vile is the effort of
the Trump administration to roll back the ACA’s mandate for insurers to cover
birth control, pandering to the religious right.

A terrific piece by Aaron Carroll
on October 10, 2017 in the NY Times, “Doubtful science behind arguments to restrict birth control access”, details and refutes the bogus claims made by
those who want, bizarrely, to do so. These include the idea that access to
contraception has not reduced unintended pregnancy (it absolutely and most
assuredly has, and greater availability would further reduce it). The Trump
(and at the time, Tom Price-led) Department of Health and Human Services used
cherry-picked and archaic data to support its tortured argument. Carroll notes
that “In 2011, the unintended pregnancy rate hit a 30-year low. And the
teenage pregnancy rate and teenage birthrate right now are at record lows in
the United States. This is largely explained by the use of reliable and highly
effective contraception.”

HHS also argues that there are
health risks, especially from hormonal contraceptives. There are, of course,
but there are health risks and side effects from any drug treatment, and the
risk of harm from the treatment has to be weighed against the probability of
benefit. Ironically, in the care of hormonal contraception, the most
significant side effects (both symptoms and even blood clots) are similar to
(if generally less severe than) those from the condition contraception is
designed to prevent – pregnancy. That is, not using contraception
because of concern about these side effects and then getting pregnant increases
the risk of these adverse events!

The bugbear for religious
conservatives in this debate is their fear that contraceptive availability will
increase people – especially teens -- having sex, but for the rest of us the
concern is how this would impact the unintended pregnancy rate. Carroll cites a
“2016 study in The New England Journal of Medicine showed that the
unintended pregnancy rate among women who earn less than the federal poverty
line was two to three times the national average in 2011. An earlier study showed that in the
years before, that rate was up to five times higher.” From a cost point
of view, the study’s author, Jeffrey Peipert, notes that “Every dollar of
public funding invested in family planning saves taxpayers at least $3.74 in pregnancy-related costs.” For women (and their partners), especially those
who are low-income or teens, the direct cost for contraception is sometimes
prohibitive, especially for the most effect type of
contraception, long-acting reversible contraception (LARC), IUDs and hormonal
implants, that have a high one-time up-front cost. It is the programs to make
these more affordable and available are exactly the ones being targeted for
major cuts. And, in the “adding insult to injury” department, the justification
for cutting some programs is sometimes the existence of other programs, which
are also being targeted for cuts!

The use of junk science, sadly but
unsurprisingly, is not limited to contraception, abortion and even climate
change. In a Viewpoint piece published in JAMA, October 10, 2017,
“Flawed theories to explain child physical abuse”, John Leventhal documents a new trend in legal
cases of child abuse. Defense attorneys bring in “medical experts” who testify
that something else could have caused the child’s injuries. These include real
diseases that could cause the findings but are both uncommon and can be ruled
out with proper workup, real diseases that are very uncommon and unlikely to
cause the findings, and essentially made-up conditions to explain the findings.
Since child abuse is generally not a controversial area (nobody claims to be in
favor of it!) the reasons for this seem to be mainly personal gain – such
“experts” make big money for this testimony. There are not that many real
experts in child trauma willing to offer absurd pseud-explanations for the injury,
so there will be fewer of you willing to testify in defense of the
perpetrators, so you again stand to make a lot more money.

In any case, the use of fake or
fraudulent science and fake facts to support political agendas is one of the
many bad things growing in the fertile “don’t try to tell me the facts” environment
in Trumpian politics. The administration is now allied with “traditional”
Republicans to facilitate rape of the planet in pursuit of gains for the
wealthiest, and with “populists” in pursuit of social repression. There is some
irony in that these advocates for “freedom” (e.g., from gun control) are so
intent on denying it to others (e.g., gays, women, poor people, children), but
apparently this is a long-standing US tradition (see: slavery), which inspired
Abraham Lincoln’s famous quote “Those who deny freedom
to others deserve it not for themselves,”
There is also irony in the pursuit of the cloak of (fake) scientific facts to
facilitate an anti-scientific agenda.

But the irony is not nearly
sufficient satisfaction to mitigate the terror.

Monday, September 25, 2017

A shorter version
recently appeared on the KevinMD blog, http://www.kevinmd.com/blog/2017/09/heres-glucometer-turned-doctor-medicaid.html

In a recent Vox
interview, Senator Brian Schatz of Hawaii announced his plans to sponsor a
bill to allow individuals without insurance to buy Medicaid coverage for
themselves. As a family doc who cares for patients on Medicaid in safety
net clinics in Senator Schatz’s home state, I cannot support such a plan.

While private insurance companies
offer supplemental insurance, Medicare continues to be run largely by the
federal government. In contrast, while Medicaid programs receive federal
funding, they are largely run by state governments. In a trend known as
Medicaid managed care, in recent decades, states have been contracting out
Medicaid to private insurance companies.

Prior to 1994, Hawaii’s state
Medicaid system was run by HMSA, Hawaii’s Blue Cross/Blue Shield. During
the Clinton presidency, the buzzword was managed competition, the idea being
that insurance corporations would compete on price to provide publicly funded
health insurance. Thus in 1994, the State of Hawaii devolved to managed
care Medicaid and started farming out Medicaid to other corporations besides
HMSA. In 2009 Medicaid managed care was extended to the aged, blind, and
disabled.

Medicaid also generally reimburses
at lower rates than Medicare or private insurance. (Senator Schatz
proposes to fix this.) However, low reimbursement is only one reason that
physicians in private or group practice take few Medicaid patients today.
Another reason is the administrative hassles to care put up by insurance
companies as well as the difficulties of dealing with multiple insurance
companies. Thus, Medicaid patients have relatively restricted networks of
providers from which to choose. Many are therefore seen by safety net
providers such as Federally Qualified Health Centers (FQHCs) or training
clinics.

The modern practice of medicine is
complicated enough, but the different requirements and different formularies of
different insurance companies complicates it to Kafkaesque levels. I
believe that the powerlessness and helplessness induced by this nightmarish
bureaucracy is a major cause of physician burnout. I want to give just
one example. Let us say that one of our patients has newly diagnosed
diabetes. Let us say that he has Medicaid. Just to prescribe him a
glucometer, I have to go through the following:

Patients on Medicaid must enroll
with one of the following: HMSA, AlohaCare, Ohana (WellCare), United
Healthcare, and Kaiser. I need to go to the insurance section of the
patient’s Electronic Health Record (EHR) to find out which insurance corporation
is responsible for this patient. Then I go to The Prescribing Guide (http://prescribingguide.com/), a cheat
sheet developed and maintained by my family medicine faculty colleague
Chien-Wen Tseng, MD. The prescribing guide tells me which brand of
glucometer to prescribe.

Each insurer contracts with a
different glucometer manufacturer, so I can’t just prescribe a generic
glucometer. I have to figure out whether to prescribe Freestyle, or
OneTouch, or AccuChek. Because the contracts are continually
re-negotiated, the preferred brand can change every six months. If you
enter the wrong brand, the pharmacy will reject it and tell you to get a prior
authorization.

Next, I have to identify the ICD-10
code that corresponds to the highest complexity of the patient’s
diabetes. Does she have nephropathy, or neuropathy, or
ophthalmopathy? I often have to review the patient’s labs to see if the
creatinine/GFR is abnormal. Am I going to place the patient on long-term
insulin? Because if I am, I can justify asking for test strips for more
than once a day testing. The number of times per day the glucose is to be
measured, the ICD-10 code, and whether or not the patient is on insulin has to
be on the prescription. If not, the pharmacy will reject it.

Now that I have prescribed a
glucometer, I can now start working on prescribing a diabetes medication.

And I’ve yet to address the
fatigue, the blood pressure, or the back pain for which his friend’s oxycodone
worked real good, Doc.

. . .

“All the world's a stage,
And all the men and women merely players” -Shakespeare

Was this theater of the absurd
composed by Alfred Jarry? Samuel Beckett? No, this play was
composed by the layers of business administration types that have piled onto
the health care system over the past couple of decades to bring corporate-style
efficiency to medicine. Insurance companies limit their costs by imposing
roadblocks. By making it so time-consuming and so frustrating to get
anything done, we physicians throw up our hands and decide, no it’s not worth
the hassle to order a different medication or sophisticated tests.
Perhaps my patient gaining weight on a sulfonylurea would benefit from a glucagon-like
peptide 1 receptor agonists or a sodium glucose transporter 2 inhibitors
instead. But the prior authorization form requires me to list the dates
that the patient has taken every other diabetes medication she has ever been
prescribed . . .

For those physicians who are
employed by hospitals or other institutions, we are finding that our employers
are engaging in an arms race with the insurers by hiring their own army of
coders and billers. These coders and billers find our documentation
lacking in order to maximize return. So now we are told to write addenda
to chart notes entered months ago - in order to justify higher
reimbursement. These coders and billers shake their heads sadly and say
to themselves, “Dr. Yamada, you are such an idiot.”

. . .

The new interns started in
July. When they were medical students, I taught them about the
pathophysiology of diabetes, about the evidence base of what treatments have
been shown to improve patient outcomes, about how to discuss lifestyle
measures, about the social determinants of the development of diabetes.
Now that they’re interns, though – all of that goes out the window. Now
that they’re managing real patients, I teach them how to enter billing codes
into the electronic health record, and how to get a glucometer covered by
insurance.

They look at me with
incredulity. They are dumfounded by how irrational and Byzantine our
health system is. They realize that I am no longer teaching them
medicine. Because there is no time for that now. There is only throughput.
Treat ‘em and street ‘em.

“Welcome to the desert of the
real,” I say. “Get used to it.”

. . .

The MBAs who manage us physicians
say, “It’s not about throughput. It’s about quality. We’re not
going to pay you for throughput any more. We’re going to pay for
performance. We don’t care how many times you see the patient. We
only care about their A1cs.”

OK, then, tell me how you get
better outcomes with a patient with diabetes without seeing them every once to
talk with the patient about diet and exercise, to prescribe a glucometer so
they can learn how diet and exercise affects their glucoses. What is the
point of telling the homeless patient to bring down their A1cs by eating more
fresh vegetables? What use is the A1c when the patient has cancer?
What does the patient dealing with domestic violence care about her A1c?
To measure the quality of care provided by a physician through A1cs is like the
drunkard searching for his keys under the streetlight because that’s where the
light is. The A1c is easily measured. Other aspects of medical care
are not so easily assessed.

. . .

Insurance companies and their
corporate mind-set have so thoroughly taken over American medicine that we can
hardly see the forest for the trees any more. EHRs, essentially designed
for reimbursement purposes, define the patient encounter – such that physicians
look only at their screens. I can’t afford to make eye contact with my
patients, or I’ll fall hopelessly behind. Was there a time that we used
to eat lunch? Nowadays, lunchtime is for finishing with charting or
dealing with phone calls. Dealing with medication refills, or lab or
x-ray results? Planning for the patients on tomorrow’s schedule? We
do that in the evenings or weekends by remote access to the electronic health
record.

Though Senator Schatz’s proposal
would make Medicaid something like the public option that didn’t make it into
the Affordable Care Act, it would likely leave intact insurance company-run
Medicaid managed care – with its restricted networks and administrative
hassles. As a practicing physician, I would like to get corporate profits
and the layers upon layers of bureaucrats out of medicine. The American
physician is in a predicament like that of Josef K in Kafka’s The Trial.
The rules are obscure and seem to be constantly changing. We are never
told what crime we committed to justify our being treated the way we are.
The sense of a lack of agency and helplessness induced is one major cause of
physician burnout. The practice of American medicine needs to be
rationalized, so that we health workers can go back to focusing on the
medicine. Medicare for All is what we need. Not all the
inefficiencies and irrationalities of the modern practice of medicine will be
fixed by Medicare for All – but patients and doctors need a way out of this
Kafka novel.

Tuesday, August 29, 2017

‘Drug Aimed at Inflammation May Lower Risk of Heart Disease and Cancer’, by Denise Grady in the New York Times, August 27, 2017, reports on a study in the New England Journal of Medicine, ‘Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease’ by Paul M. Ricker, et al. The study, funded by the drug’s manufacturer, Novartis, examined the impact of the use of canakinumab (brand name: Ilaris) on heart attack survivors. The drug is in a class called “monoclonal antibody inhibitors” (as is almost anything ending in “…mab”); in its case, it inhibits antibodies known as “interleukin 1β”. The main effect is anti-inflammatory, which is why it was originally developed for treatment of juvenile rheumatoid arthritis, an inflammatory disease. However, research showing that inflammation plays a major role in coronary artery disease (the cause of heart attacks) stimulated this large multi-center, drug-company sponsored, trial.

So what did the study show? Of the over 10,000 people in the study, those who were treated with canakinumab had lower rates of what the study designers defined as the “primary end point”, the main thing that they were looking for, “nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death.” That is, did patients have another heart attack or stroke, whether they lived or died. The lower rates in the canakinumab groups were statistically significant, with the group that did the best, the middle-dose (they tested 3 different dosages), having 3.86 “events” per 100 person-years, compared to 4.50 for the placebo group. In absolute terms, there were, thus, 0.64 fewer “events” for each 100 person-years (which is a valid concept, one person taking a drug for 100 years, or 100 people for one year, or any combination in between).

There was, however, no significant difference in “all cause” mortality between the treated and untreated groups, mainly because of the increase in deaths from infections in those treated. This is not surprising because the anti-inflammatory effect of canakinumab also decreases the body’s immune response. It is also not surprising that the people most likely to die of infection were those who were oldest and sickest in the first place. Six people developed tuberculosis.

Given that the cost of the drug is about $200,000 a year (think about that!), 100 person-years of treatment would cost $20,000,000. And for this price, 0.64 fewer people have a cardiac “event”, and no fewer people die. And some untold number suffering serious side effects from canakinumab, including the infections that occurred that didn’t kill them (not reported). These could be really serious – long hospitalizations for sepsis or pneumonia or cellulitis, non-fatal but significant events like amputations, etc. No wonder the Times article quotes Dr. David J. Maron, the director of preventive cardiology at Stanford University School of Medicine, as saying “This is fantastic”! Dr. Maron, I imagine, has terrific insurance.

Of course, it didn’t cost Novartis $200,000 a year for the drug for the study; that is the retail price that it plans to charge hospitals, insurers, and patients. We have no idea what the drug actually costs Novartis to manufacture; the price they will charge is based on the highly scientific formula called “what the market will bear”. For their own bizarre reasons (see Elizabeth Rosenthal’s “An American Sickness” and this commentary by Jacob Hacker) insurers may gladly pay for this drug (they get to keep a percent, and a higher price means a higher percent, and they just raise rates). Or they may get a discounted charge. Certainly, many poor and uninsured people are not likely to get it. Maybe – probably – Novartis will have a program for giving the drug for little or no money to poor people. But, given how common coronary heart disease (CHD) is, they are incredibly unlikely to give it for free to every uninsured person who has CHD. Maybe they’ll give them a discount, say 90%. Then the poor person would only have to pay $20,000 a year out of pocket. To reduce their risk of another coronary event by 0.0064 per year. And have no lower likelihood of dying. And a greater likelihood of severe infection. Maybe this is, after all, a boon to the poor and uninsured, as they are unlikely to get this terrific opportunity.

The other amazing thing is the actual story in the Times, and what that says about health journalism. As noted by the insightful Howard A. Rodman, the

·Headline says: "Drug... May Lower Risk of Heart Disease and Cancer"

·The 2nd paragraph tells us it is a "major milestone"

·The 3rd paragraph quotes Dr. Maron saying "This is fantastic."

But then you have to scroll down to find

·In the 5th paragraph, that the drug costs $200,000 per year. It's available only from Novartis, and that Novartis paid for the study.

·And in the 7th paragraph, that the drug suppresses immune response. In the study, the number of deaths from drug-caused infections equaled the number of lives saved.

Lead with the positives, and then let us down later, maybe after those of us scanning the article have stopped reading.

Is the Times trying to mislead us? I don’t think so. I think that they want, however, to get our attention, get us reading, show us blockbusters. Blockbusters are good for getting attention. It is a big article for the New England Journal of Medicine also. This is why there is a built-in prejudice in medical journals for publishing articles with positive results, and why the authors do their best to “spin” results to positive. As if the incredible amount of work they have put in to the study, not to mention the interest of the sponsor, in this case, a pharmaceutical company that makes the drug in question, was not sufficient impetus. After all, getting our attention is what it is all about; it is why reality TV is so big, and why a reality TV star is now POTUS; see Matt Taibbi’s piece “The Media Is the Villain – for Creating a World Dumb Enough for Trump”. He notes that “If a meteor crashes into jello night at the Playboy mansion, it doesn't matter if you send Edward R. Murrow to do the standup. Some things sell themselves.” Maybe a drug that treats a disease that treats heart disease isn’t that big, but it is big; after all, as Grady notes, “Cardiovascular disease is the leading cause of death worldwide and in the United States, where it killed nearly 634,000 people in 2015. Globally, it killed 15 million,” (paragraph 4, if you’re tracking it).

Neither does this mean that published scientific research is unreliable. Some of it is very good science (even this study is generally good science, despite the published report in NEJM and the coverage in the Times being unconscionably skewed to the positive). Some of it actually reports on drugs or other interventions that make a difference. Sadly, however, in addition to the “blockbuster” effect that the media (including medical journals) want to cover, those interventions that will make a lot of money for a company get more publicity. Especially when the company funds the research. Aspirin, by the way, is still cheap, and it is more effective than this drug, recommended by the US Preventive Services Task Force (USPSTF) for prevention of CHD in adults with greater than a 10% 10-year risk.

I tell medical and other health professions students (at all levels) that, although the Introduction and Discussion sections of the article may seem most interesting, the important parts to read are the Methods and Results, which have the meat (or soy, if you’re vegan) and from which you should draw your own conclusions, without the authors’ spin. If you’re not a health professional, and depend on the mass media for coverage, then you better read the whole article and not stop after the fanfare. It is the reporter’s job to provide the necessary information, but your job to read it wisely.

Certainly, health professional or reporter or consumer, look at who is funding the study. It is important information. And think about conflict of interest. And think, of course, about cui bono. It is likely to be the manufacturers, and maybe the researchers, and sometimes those who are wealthy or well-insured enough to get the drug or intervention (when it is of benefit).

And, surprise, it is never likely to be the poor, uninsured, or those most in need.